Chronic obstructive pulmonary disease (COPD) is a common respiratory condition affecting 15 million Americans (Centers for Disease Control and Prevention [CDC], 2021) with millions more undiagnosed and not receiving needed treatment. It is the fourth leading cause of death in the United States, exceeding 150,000 American deaths yearly (CDC, 2021). Globally, by 2030, COPD is expected to be the third leading cause of death (World Health Organization, 2017). Early health education regarding COPD management can help minimize symptoms and prevent exacerbations, thus improving quality of life. Knowledge of disease pathology, clinical presentation, medication management, potential complications, and unpredictability is, therefore, an essential skill for home care clinicians in managing patients with COPD.
COPD, Chronic Bronchitis, and Emphysema
COPD is a group of lung diseases caused by an inflammatory process leading to airway narrowing, destruction of alveoli, constriction of the bronchioles, limited airflow, and decreased gas transfer capacity. The damage to the lungs cannot be reversed (National Institute of Health [NIH], 2022). The airflow limitation is determined by severity of inflammation, extent of fibrosis, and secretions (Sun & Zhou, 2019). On exhalation, diminished airflow traps air, causing decreased inspiratory capacity and dyspnea. This limits gas transferring and results in hypoxemia and hypercapnia (Sadeghi, 2022). In the United States, emphysema and chronic bronchitis are the two most common conditions contributing to COPD. Though COPD is a progressive disease, patients can achieve symptom control and better quality of life with proper management.
Smoking is the primary cause of COPD, as well as genetic susceptibility, exposure to secondhand smoke, and air pollution (Ranjan et al., 2019). Exertional dyspnea is the primary manifestation; however, the feeling of breathlessness is subjective (O'Donnell et al., 2020). Breathing difficulty produces distress and uneasiness, but this response, as observed by clinicians, can differ from person to person. A persistent cough, also known as "smoker's cough," is often the first sign of COPD (Colak et al., 2021). Individuals who have smoked or are currently smoking may believe their persistent cough is the price to pay for smoking rather than recognizing it as a sign of COPD. Typically, patients with COPD have excessive sputum production due to the overproduction of mucus, which is complicated by reduced mucus elimination. Other signs and symptoms include shortness of breath (SOB), wheezing, chest tightness, and swelling in the lower extremities. Unintended weight loss can occur in later stages of the disease (Vogelmeier et al., 2020).
Chronic bronchitis is diagnosed when the patient has a productive cough lasting at least 3 months in 2 consecutive years (Widysanto & Mathew, 2021). This long-term bronchial inflammation causes productive cough, wheezing, SOB, and chest pain (Lareau et al., 2019). Smoking, exposure to secondhand smoke, and air pollution are significant causes of chronic bronchitis (Widysanto & Mathew, 2021). Pulmonary function tests, chest X-ray, and computed tomography confirm a diagnosis of chronic bronchitis (Lareau et al., 2019).
Emphysema progresses gradually with alveolar destruction causing the tiny air sacs to rupture, creating one large air pocket instead of many small ones (Lu et al., 2021). This causes a reduction in lung surface area and loss of elasticity. Air gets trapped in the damaged alveoli, preventing the movement of oxygen into the bloodstream and the removal of carbon dioxide (Lu et al., 2021). The lungs gradually overfill, making breathing difficult. Signs and symptoms include breathlessness, productive cough, wheezing, and chest tightness (Duffy & Criner, 2019). Tests used to confirm the diagnosis of emphysema include pulmonary function tests, chest X-ray, pulse oximetry, arterial blood gases (ABGs), and electrocardiogram (Buendia-Roldan et al., 2020). In the United States, more than three million individuals have been diagnosed with emphysema (National Emphysema Foundation, 2021). It is important to note that this is a preventable respiratory disease because the most common cause of emphysema is smoking, a modifiable health risk behavior (Duffy & Criner, 2019).
A diagnosis of COPD should be considered in all patients who smoke or previously smoked, are age 35 or older, and have associated indicators such as chronic productive cough, wheezing, and dyspnea (National Institute for Health and Care Excellence [NICE], 2019). Accurate assessment allows home care clinicians to respond to changes in symptoms that occur with disease progression or exacerbation, thus reducing hospitalizations.
Diagnosis
Diagnosis is generally confirmed by signs and symptoms, history of smoking or exposure to lung irritants, family history, and pulmonary function tests (Lareau et al., 2019). On occasion, computed tomography and ABG analysis may also be used to confirm COPD diagnosis (Ramakrishnan et al., 2021). Spirometry is used to measure lung function. There are two key components to this test: the amount of air that can be exhaled in 1 second (forced expiratory volume [FEV1]) and the total amount of air that can be forcefully exhaled in one breath (forced expiratory volume [FVC]; Hammer, 2019). The FEV1 and FVC numbers are lower than average in patients with COPD and worsen progressively as the disease progresses (Hammer, 2019). Table 1 describes FEV1 parameters for grades I-IV of COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2022).
Chest X-rays, although frequently ordered for patients with COPD, are typically used to rule out other causes of dyspnea (Hammer, 2019). High-resolution computed tomography scans are not currently recommended as a screening or diagnostic tool for patients with COPD (Hammer, 2019); however, they may be used for some patients to view the structures of the heart, lungs, and blood vessels (Ho et al., 2019). For patients experiencing acute exacerbations, ABGs may be drawn to determine blood oxygen, carbon dioxide, and pH balance and whether there is a need for home oxygen therapy (Duffy & Criner, 2019).
Subjective Assessment
Ask the patient about their SOB and whether it occurs at rest or with exercise, how often it occurs, whether it is getting worse, and how far they can walk and how many stairs they can climb before becoming SOB. Questions related to coughing include when and how often the cough occurs, whether it is getting worse, whether it is productive, and if so, color and consistency of sputum. Question the patient to ascertain their smoking history. If the patient responds in the affirmative, ask how long they have been smoking and how many cigarettes/day. If the patient is a former smoker, ask about their smoking history prior to cessation (how many packs per day and for how long). Inquire about exposure to airborne irritants such as dust or chemicals. Elicit history regarding childhood respiratory illnesses and family history of respiratory disease. Ask the patient about comorbidities such as gastroesophageal reflux and heart failure, which can aggravate COPD symptoms (GOLD, 2022). Chronic hyperglycemia from poorly controlled diabetes can trigger an increased occurrence of respiratory infections leading to declining lung function and increased dyspnea (Hammer, 2019). Ask the patient about the impact of COPD on their quality of life, including missed work, disrupted routines, and/or depression. Conduct medication reconciliation including over-the-counter products. Lastly, assess family and social support networks. As the work of breathing becomes more challenging, there is an increase in calorie requirements (Keogh & Williams, 2021); therefore, ask focused questions about nutritional habits. Individuals with dyspnea often struggle to eat, leading to weight loss and poor nutritional status. Evaluate for skeletal muscle wasting and cachexia.
Sleep problems are common in patients who suffer from COPD due to difficulty with breathing when sleeping. They may have trouble falling asleep due to breathlessness or may wake very early in the morning. Sleep deprivation adversely affects memory, focus, mood, and judgment. To determine if a patient is having issues sleeping, assess for orthopnea. Inquire how many pillows they use to make nighttime breathing more comfortable. If patients complain of breathlessness at night, overnight pulse oximetry may be needed to determine if they suffer from nightly low oxygen saturation. Patients with COPD may also suffer from obstructive sleep apnea and require continuous positive airway pressure or bilevel positive airway pressure at night (Yawn, 2020).
Objective Assessment
Physical assessment will provide vital information regarding the patient's current condition and disease progression. Begin by collecting baseline data, including temperature, blood pressure, respiratory rate, pulse, oxygen saturation, weight, height, and body mass index. These findings are important in assessing the patient's general physical health and may identify COPD progression. Next, examine the eyes, ears, nose, and throat for signs of infection. Auscultate the lungs, listening for wheezes and diminished breath sounds, and assess for paradoxical movement of the lower ribs. Observe for pursed-lip breathing, use of accessory muscle, and barrel chest (suggesting hyperinflated lungs). Right-sided heart failure (cor pulmonale) occurs when oxygen levels are low, causing an increase in pulmonary artery pressure and placing strain on the right ventricle (Guder & Stork, 2019). Observe for signs of right-sided heart failure that include jugular vein distention, lower extremity edema, and ascites (NICE, 2019). Auscultate the heart, assessing for rate and rhythm.
In the initial stages of COPD, respiratory findings may remain within normal limits. However, as the disease progresses, oxygen saturation may fall with physical exertion and then recover at rest (COPD, 2018). When auscultating the lungs, you may hear wheezing or rhonchi during an exacerbation of COPD. Breath sounds can then return to normal when the acute illness resolves. As COPD progresses, diminished breath sounds may be noted, especially in the lower lobes (COPD, 2018). In the later phases of the disease, wheezing and/or diminished lung sounds will be common findings, attributed to alveolar collapse (Rocha et al., 2019). Patients often assume the tripod position as an adaptive technique, leaning forward and supporting their upper body with their hands on their knees (COPD, 2018). This position assists with opening the thoracic cavity, making breathing less labored. Due to pulmonary hypertension, patients may have a loud S2 (pulmonic valve closure) heart sound (NIH, 2021).
Dyspnea is readily observable, yet breathlessness is subjective and varies from person to person (Hammer, 2019). Objective dyspnea assessment tools should be incorporated in the assessment. Three examples are the Visual Analog Scale (VAS), the Borg scale, and the Medical Research Council Dyspnea Scale (MRC Dyspnea Scale). The Borg scale (1982) and VAS (Gift, 1989) consist of one question with a response of 0 (breathlessness) to 10 (maximum breathlessness). These single-item scales do not involve a complex scoring method and are valuable in determining the management of breathlessness. The MCR Dyspnea Scale is frequently used to assess breathlessness when the patient is completing physical tasks. It is a 5-point Likert scale ranging from 0 (no trouble excluding strenuous exercise) to 5 (extremely acute and cannot leave the house; Fletcher, 1960).
Management
The goal for COPD patients is to prevent hospital readmission and therefore continue to live in their homes. Home care clinicians can play a vital role in assisting with COPD self-management and promoting optimal health with targeted interventions to improve wellbeing. The focus is on preventing and minimizing decline; preventing exacerbations, reducing symptoms and preventing complications, so lung function is not lost. Pharmacological and nonpharmacological interventions are used to prevent long-term decline in lung function (Hammer, 2019).
Pharmacological Management
Pharmacological treatment is used to manage symptoms. Table 2 lists common medications and side effects. Educate patients about the following:
* Potential medication side effects (e.g., oral candidiasis, hoarse voice, dry mouth). Instruct patients to rinse their mouths and gargle after using inhaled steroids to prevent candidiasis.
* Appropriate technique for administering inhalation medication and the use of spacer devices.
* Distinguishing short-acting rescue inhalers from long-acting.
* Appropriate storage and cleaning instructions for inhalation devices.
Inhalation devices are commonly misused by patients, leading to inappropriate medication administration. Detailed instructions with a "teach back" approach will be helpful to ensure proper use. The COPD Foundation (2002) website (https://www.copdfoundation.org/COPD360social/Community/Get-Involved.aspx?gclid=C) provides excellent teaching videos. Home care clinicians can utilize the videos as a visual aid and encourage patients to view videos frequently to support continued appropriate use of devices.
Some patients may suffer from anxiety and depression, requiring medication management. These may include selective serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors, serotonin modulators, monoamine oxidase inhibitors, or tricyclic and tetracyclic antidepressants (Yohannes et al., 2018). The most common of these medications is SSRIs. Advise patients that SSRIs take at least 2 weeks to see changes and up to 12 weeks for full effect (Yohannes et al., 2018). Emphasize the importance of continuing the medication as the patient begins to feel better.
Patients suffering from productive coughing and SOB may have a bacterial infection requiring antibiotic treatment (Moore, 2020). Educate patients about the specific medication-some antibiotics must be taken with food, and others must be taken on an empty stomach. Emphasize the importance of continuing the prescribed amount for the directed length of time.
Oxygen therapy is not used to prevent or treat dyspnea directly; it is used to correct hypoxia. Oxygen is prescribed for COPD after assessing ABGs (Branson, 2018). Long-term oxygen therapy may be initiated when the arterial partial pressure of oxygen (PaO2) < 7.3 kPa. Oxygen therapy may also be initiated for patients with a PaO2 < 8 kPa coupled with comorbidities such as pulmonary hypertension, secondary polycythemia, or peripheral edema (NICE, 2019). Teach patients about the proper use of oxygen equipment and be alert for oxygen therapy safety matters, including fire risks and possible falls due to the long tubing. Oxygen therapy should never be initiated for a patient who has not stopped smoking (NICE, 2019). Additional education should focus on the ability to self-monitor pulse oximetry, including keeping a daily log and maintaining an oxygen saturation of at least 90% (Branson, 2018). Oxygen therapy may be used to increase exercise capacity in patients who experience desaturation with exercise; however, it should be prescribed after a healthcare professional completes a formal assessment (NICE, 2019). For COPD patients at risk of hypercapnia, oxygen therapy should be prescribed to support an oxygen saturation of 88% to 92% (O'Driscoll et al., 2017).
Nonpharmacological Management
Instruct COPD patients on the technique of controlled coughing (Solomon et al., 2017). This is a cough that comes from deep within the lungs and has enough force to loosen and carry mucus through the airways without causing narrowing or collapse. Instruct the patient to sit in a chair and inhale through their nose. They should then lean forward to exhale while pressing their arms across their abdomen followed by short sharp coughs two to three times. The first cough loosens the mucus and subsequent coughs allow the person to move the mucus through the airways. The next inhalation should be slow and gentle to prevent mucus from moving back down the airways (Cleveland Clinic, 2018). This type of cough conserves oxygen and prevents fatigue.
Also teach the patient about diaphragmatic breathing and pursed-lip breathing. Diaphragmatic breathing involves using the diaphragm and abdominal muscles to fully expand the lungs. It slows the respiratory rate, increases alveolar ventilation, and helps expels mucus during expiration (Mendes et al., 2019). Pursed-lip breathing is another technique that helps slow expiration, prevents collapse of small airways, and helps expel retained carbon dioxide (Mendes et al., 2019). Instruct patients to exhale through puckered lips to create back pressure and open collapsed airways.
Education regarding smoking cessation is one of the most important management strategies for patients with COPD because this is a fundamental approach to slowing COPD progression. Smoking is one of the modifiable behaviors that can help prevent lung disease. Research suggests that behavioral interventions combined with medication management are the most effective approach to achieving success (Liang et al., 2018). Evidence highlights improved cessation rates using brief personalized counseling, nicotine replacement or medication provision, and follow-up visits (Hammer, 2019).
Patient education should also include the importance of immunizations, including pneumococcal vaccines and the yearly influenza shot (CDC, 2021). These vaccines assist in preventing infections and subsequent exacerbations of COPD. The CDC (2022) presently recommends that patients with COPD should also receive the COVID-19 vaccine.
Education should focus on minimizing exposure to inhalants. Encourage those with occupational risk to wear adequate protective masks to shield themselves from fumes, dust, and vapors (Hammer, 2019). If patients use wood or biofuel stoves, these should be vented outside and remain tightly sealed to prevent indoor leaks (Hammer, 2019), which can exacerbate COPD.
If COPD is mild, the treatment objectives are to increase exercise tolerance and prevent further loss of pulmonary function (Barbosa et al., 2022). To improve activity tolerance, teach patients to pace daily activities to conserve energy expenditure. Educate on exercises that help strengthen upper and lower extremity muscles and improve exercise tolerance and endurance. Patients may need to use walking aids to improve activity levels and ambulation.
The physical challenges for patients living with COPD can often impact mood and emotional health. Educate on anxiety and depression, which are common in patients living with COPD. Shortness of breath can cause anxiety and panic attacks triggering an increased respiratory rate, making SOB worse (Hammer, 2019). Instruct patients about avoiding emotional disturbances and stressful situations. Patients may benefit from relaxation techniques and breathing exercises. Some may benefit from self-reflection; journal writing may help them process their feelings. Locate COPD support groups in the area. Attending meetings when able has the added benefit of getting out of the house and connecting with others who understand what it is like to live with the disease.
Exposure to heat and cold can trigger symptoms for many patients with COPD (Hammer, 2019). Discuss the need for consistent temperature control in the home and avoiding extremes of heat. Heat can increase the patient's temperature, potentially increasing oxygen requirements leading to hypoxemia. Encourage hydration. Perspiration is a mechanism for the body to stay cool, so adequate hydration is necessary for effective sweating (Hammer, 2019). Educate patients on preparing for outdoor temperature extremes and encourage them to listen to local weather reports to assess the severity of the weather, considering the heat, humidity, and pollution advisories. In hot climates, outings should be limited to early morning or late afternoons to avoid overexertion when sun and heat are most intense.
Patients who suffer from COPD may need education on nutrition that can affect their respiratory status (Hammer, 2019). When carbohydrates are metabolized, they produce carbon dioxide at a greater rate than when fats are metabolized. Some patients with COPD may find their breathing is easier when they eat fewer carbohydrate and include more fat in their diet (American Lung Association, 2021). Other nutrition tips include not overeating and avoiding gas forming foods as both can make breathing more difficult.
Conclusion
COPD is a multifaceted disease, causing significant challenges for patients regarding physical abilities and mental and social wellbeing. Patients with this condition will require frequent and ongoing assistance as their disease progresses due to the frequency of exacerbations and complexities of COPD management. Home health clinicians, therefore, play a central role in improving the patient's quality of life and optimizing their overall health.
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